Health Care and Society

Dear Julian,

It’s been a while since we’ve chatted, and I was curious as to your take on the health care brouhaha.

In this case I have some pretty strong opinions which are decidedly not Libertarian. In fact, I find myself becoming increasingly socialist. Unfortunately, I’m not sure that socialism in any form is compatible with our “cowboy” brand of democracy, which is (IMO) good for very little at all.

Here’s the nub of it: humans are social animals. It’s how we survive. The so-called “lone wolf” human simply does not do well in even a survival sense, much less in any sense of thriving. Most of those today who consider themselves “self-reliant” simply take for granted the smooth functioning of an immensely interdependent civilization around them. They are like the “low carbon footprint” environmentalists who look to the Internet for salvation, because “computers don’t take much electricity.” True, but a typical chip fabrication clean-room takes a whole LOT of electricity, and produces a whole lot of extremely toxic waste, all of which had to be mined using machinery that used petrochemicals and be refined using energy-intensive processes invented by people who were fed, clothed, housed, and entertained while they spent day after day doing nothing but thinking about matters so abstract and specialized that only a few dozen people in the world really understand them when they talk about their work…. The Internet has an unthinkably enormous carbon footprint.

As social animals, the issue of community is not how we live when things are going perfectly, the game and berries are abundant, when we’re young and strong and healthy, the sun is shining and the birds are singing. The issue is how we get through the lean times. That’s when we need community: when we can’t contribute due to age, illness, or injury, or when the harvest fails, or the game moves on, or the banks run off with all the money; when we must rely on the healthy to care for the sick, the well-off to share with the poor.

One answer to the issue is, of course, “Let them eat cake.” Who needs the hungry, the poor, or the ill? Let them fend for themselves, or die. We can’t afford to carry dead weight around. Remember the Grasshopper and the Ant. It’s their fault, anyway, for being (…fill in the blank…) Having experienced both serious illness (cancer) and now having been tossed around financially by circumstances only marginally under my control, I’d have to call this “fair weather community” concept amazingly dim. To say nothing of brutal, and ultimately self-destructive. What happened to Marie Antoinette? I forget.

Rejecting this Bourbonesque solution, then, the question is, where will our locus of community lie? At the family level? The municipal level? The state? The nation? The global human family? Where do we turn when times get tough? Who cares for us when we are sick?

There is an anti-social fringe that seems to want to keep it to isolated nuclear families. These are the folk who, should civilization collapse, will likely starve in their heavily-armed mountain redoubts while trying to figure out how to chew gunpowder. Good idea or bad, it’s far too lonely an existence for my taste.

Certainly my wife would be my first caregiver, as I would be hers. As I have been hers this last year. But it takes a toll on the caregiver, puts pressure on the care receiver, and if there are still kids in the house, it can be overwhelming. Caregivers themselves drop from exhaustion. The nuclear family is simply not robust enough to reliably survive lean times.

There is another group that wants to return to the clan. Jim circulated an interesting blog entry the other day on our drumming list, but unfortunately copied the whole article rather than posting a link. I can forward it if you are interested, or you can look it up using the information at the end of this e-mail. The blog is based in part upon the author’s reading of David Hackett Fischer’s book Albion’s Seed: Four British Folkways in America; he talks about the Borderers, whose cultural memes he believes have come to dominate the modern Republican party.

As described, the Borderer clan isn’t very much to my liking, either. Coming from the borderlands involved in the centuries-long power struggles between the English and Scottish kings, where outlawry became an honored profession, it’s pretty much the Wild West — or the Hatfields and McCoys — but where there is no difference between the black hats and the white hats. It is a culture that provides tremendous individual opportunity for the very, very few, and poverty, social chaos, and frequent death for pretty much everyone else. If you’re lucky, charismatic, unscrupulous, and persistent, you get to be the cattle baron. Otherwise, you work for the cattle baron and settle for dollar whores on your one night off a week.

The settled extended family has always drawn me, probably however because I’ve never experienced it. I have experienced the local community of happenstance (neighborhoods) and of choice (the drumming circle, the Druidic circle, or the local church in years past), but that’s where I’ve noticed something interesting: the American Dream destroys families and communities.

Let me explain that remark with an analogue to marriage — how well does a marriage do when both parties are constantly looking to “trade up” in partners? Obviously, not long: the grass is always greener on the other side, so instability in such a marriage is the rule.

The American Dream in its most generic sense, the sense that has drawn immigrants (legal or illegal) for centuries, is the dream of Opportunity — endless upward social mobility in a true meritocracy. “There’s always room at the top for talent” or “You can grow up to be anything you want to be.” All around the world, this is the mythology of America. Every individual raised here is trained from a young age to “trade up” at every opportunity.

This came to my attention when I was reading about the Dutch, who have a saying, “If you are born a dime, you will never be a quarter.” When I first read this, I thought it stultifying and pathetic. But then I started thinking about my own situation, my own neighborhood. I live in a townhome: I chose this when I was single and living alone because I wanted the sounds of other people and of human life around me. If I fell down the stairs, I wanted to able to scream and be found before I died of thirst. Neighbors come into this development — then as soon as their lot in life improves, they “move to the suburbs.” I’ve read articles written by people who grew up in the neighborhoods of Brooklyn in the 1950’s, true little communities with grandparents, children, the village idiot, and the town drunk, and the pattern is the same: add a little affluence, and people immediately move to the suburbs where they live mostly-isolated lives. Endless social advancement is the foundation of the “rat race” my father used to talk about, and the Peter Principle (“workers always rise to their level of incompetence”), and any number of the perpetual stressors that form the fabric of the American life I’ve lived. People from other countries talk about their belief that the streets of America are paved with gold; they are invariably shocked to find out how much and how hard Americans have to work for everything. We would be equally shocked to discover how little they work. Even the “industrious Germans” take six weeks’ vacation a year. Americans have no time for what non-Americans consider to be life itself.

We now have a little fair-weather community around my home, with some potential for foul-weather as well: Barb, the hairdresser with her in-home studio, Kathy the mail carrier, Zach who is always traveling on business, Lynette and her three kids…. If my income doubled, would I stay here? If their income doubled, would they stay here? It’s a sweet little place — a bit too small (what place isn’t?) but warm, manageable, and with beautiful energy, trees and neighbors. Why would I move? Yet with a doubled income, I would likely be shopping for a new house. We are imbued with the endless itch to trade up.

So I blame it on the American Dream itself — but whatever the cause, it’s a longstanding observation that for white people, the extended family is defunct. You still see the extended family in Hispanic and Asian immigrant communities, and some Black communities, although as each of these communities acculturate, the extended families tend to break apart. Something in American society destroys the extended family and local communities. So I really don’t see much hope there. It certainly would not apply to me.

Moving up in scale, we simply no longer have self-sufficient villages. That’s where most settled people have lived for tens of thousands of years, so it’s a reasonably stable level, and fits well with our ability to deal well with only about 100 people — much larger than that and we pass beyond our ability to rely upon oral tradition and elders, and start needing laws and leaders. It seems to me that villages are incompatible with industrialization, which is when they started vanishing — industrial technology requires a degree of specialization that takes more than 100 people to maintain. You can still have “bedroom communities” of 100 people (or less), but they are completely dependent upon a functioning larger civilization around them.

So that means the first viable level of true community in modern society is either at one of the levels of “taxing authority” — the city, the county, the state, or the nation — or the impersonal for-profit or non-profit institutions that provide goods and services for pay.

I summarily exclude the services-for-pay organizations, having had far too much unhappy experience with those lately. They are the quintessence of “fair-weather friends.” If you can pay, they are your dearest friend. If you cannot, they’ll set the dogs on you. They “aren’t running a charity.” They are, of course, happy to lend you money, at interest. Any debt incurred during a serious illness is almost certainly unmanageable.

So we’re pretty well stuck with tax-based levels of government, or nothing.

In principle, I have no overwhelming problem with keeping services below the federal level, but making Medicare state-run doesn’t make it any cheaper. It actually makes it inherently more expensive. So our current tax-burden would shift from federal to state, and would increase.

In practice, it would be disastrous, because the states as constituted aren’t really economically viable: we’d break instead into five or six superstates, meaning Colorado (and Wyoming and….) would be dominated by Texas, which I cannot see as a good thing in any light.

So to whom do I turn in hard times? Especially times of sickness, when I cannot pay my way, and may even incur a debt which can never be paid back?

In America, the answer is the federal government, the bad joke of “private insurance,” or no-one: pay until you go broke. If there is some other viable source of community succor, I’d sure like to know what it is.

Private insurance is economically upside-down, because it isn’t properly a business at all, but a community hedge fund. It is exactly the same as storing grain against a bad harvest. If emergency grain storage were run like private insurance, a) you would not be allowed to participate if you had ever been hungry (pre-existing condition), b) you would have to come up with your own grain for a month before they would open the doors (high deductibles), and c) you would have to pay enough grain into the fund (premiums) to allow the fund managers to run a profitable distillery (exorbitant medical costs and insurance profits).

Because the insurance and the health-care providers form a closed loop without regulation by anyone, neither has any incentive to reduce medical costs. Pharma can produce drugs that cost $25,000 per dose. Hospitals can charge $4000 for a visit to the emergency room. The insurance company likes to see this, because these astronomical costs make health insurance necessary — so they sell more, at higher premiums and higher profits. If basic medical costs dropped to even approximately affordable levels, people would drop health insurance like a burning hot potato — I know I would. Insurance companies would be forced to cut their premiums to get any customers at all, and profits would drop precipitously.

So the only place insurance is at all interested in “controlling costs” is by denying payment to clients through technicalities and loopholes. This was the whole twisted idea behind the HMO of Hillarycare in the 1990’s, and which I got to experience firsthand in the mid-1980’s in Denver with Cigna.

Just for reference, by the way, our health insurance premiums will be $900/mo starting Oct 1, for a policy with a $6000 annual deductible ($3000 each). That’s $11,000 we’ll shell out every year whether we get sick or not. That’s a massively regressive tax of 10% on a $110K annual income. If we do need the coverage (i.e., we get sick), it’s a 15.5% tax. I have to compare it to a tax, because in every other industrialized nation, it is completely covered (or nearly so) by taxes.

All of this completely inverts the economics of health care, and I even remember reading about this back in the early 1970’s, when I was in high school. Medical costs were starting to inflate back then, and people were writing about how the insurance industry was driving up the costs. Market economics simply don’t apply to the health-care industry under private insurance. They never have. Insurance companies will never control health-care costs. You might as well wish to squeeze orange juice out of a dairy cow.

So the proper solution to this, it seems to me, is direct government involvement, as is the case in every other industrialized nation. There are dozens of systems out there, from the German, to the French, to the English, to the Canadian, to the Swedish…. Or even our own Medicare.

Even the GP’s we see are passionately in favor of going to fully socialized medicine at this point.

Sorry for the long rant, but I hope it had enough substance to hold your interest. I’m curious as to Julian’s take (you don’t have to pretend to speak for anyone else :-)).

— Themon

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